Surgeon-performed ultrasound is superior to 99Tc-sestamibi scanning to localize parathyroid adenomas in patients with primary hyperparathyroidism: results in 516 patients over 10 years.

BACKGROUND

Surgeon-performed cervical ultrasound (SUS) and 99Tc-sestamibi scanning (MIBI) are both useful in patients with primary hyperparathyroidism (PHPT). We sought to determine the relative contributions of SUS and MIBI to accurately predict adenoma location.

STUDY DESIGN

We performed a database review of 516 patients undergoing surgery for PHPT between 2001 and 2010. SUS was performed by 1 of 3 endocrine surgeons. MIBI used 2-hour delayed anterior planar and single-photon emission computerized tomography images. Directed parathyroidectomy was performed with extent of surgery governed by intraoperative parathyroid hormone decline of 50%.

RESULTS

SUS accurately localized adenomas in 87% of patients (342/392), and MIBI correctly identified their locations in 76%, 383/503 (p < 0.001). In patients who underwent SUS first, MIBI provided no additional information in 92% (144/156). In patients who underwent MIBI first, 82% of the time (176/214) SUS was unnecessary (p = 0.015). In 32 patients SUS was falsely negative. The reason for these included gland location in either the deep tracheoesophageal groove (n = 9) or the thyrothymic ligament below the clavicle (n = 5), concurrent thyroid goiter (n = 4), or thyroid cancer (n = 1). In 13 cases, the adenoma was located in a normal ultrasound-accessible location but was missed by the preoperative exam. In the 32 ultrasound false-negative cases, MIBI scans were positive in 21 (66%). Of the 516 patients, 7.6% had multigland disease. Persistent disease occurred in 4 patients (1%) and recurrent disease occurred in 6 (1.2%).

CONCLUSIONS

When performed by experienced surgeons, SUS is more accurate than MIBI for predicting the location of abnormal parathyroids in PHPT patients. For patients facing first-time surgery for PHPT, we now reserve MIBI for patients with unclear or negative SUS.